I recently returned from the annual meeting of the North American Congress of Clinical Toxicology, which attracted hundreds of interested toxicologists, poison specialists, poison center administrators, residents, and fellows-in-training.
As usual, the meeting consisted of many important platform lectures and interesting courses. There also were hundreds of thoughtful poster presentations I always find interesting and informative. Some of the most intriguing poster presentations are summarized here, but they represent only a small percentage of the 230 abstracts presented. Abstracts for the following posters can be found in the Journal of Toxicology Clinical Toxicology (2002;40[5]).
One of the most interesting (and entertaining) posters was presented by H.P. Robertson, MD, from the Washington Poison Center in Seattle. The unlikely title of this poster was Abbreviation Abuse-Still More B.S. This poster notes that in the 1970s the Joint Commission on Accreditation of Hospitals (JCAH, formerly the JCAHO) began to require hospitals to develop a list of approved abbreviations unique to the practice in that institution.
Dr. Robertson concluded that there are far too many abbreviations in use in medicine (and toxicology) today, and that they are a prime source for medical errors. Some of these errors may produce lethal results. This poster was a report of a study that Dr. Robertson conducted using a 15-item survey that listed approved abbreviations for various medical terms. Less than 55 percent of the respondents were correct when asked to interpret these so-called approved abbreviations.
Dr. Robertson pointed out that the abbreviation B.S. (bowel sounds or breath sounds) was interpreted correctly by only about 80 percent of those queried. He is quick to add that Logan's Medical Abbreviations, a reference for medical abbreviations, lists about 30 other approved meanings for the abbreviation B.S. Dr. Robertson quipped, however, that it does not include the most common usage of that abbreviation.
Baking Soda for Colic
Another interesting poster was presented by Drs. Bryant, Feldman, Milner, Sparks, and Hryhorczuk from the Toxikon Consortium-Cook County Hospital, the University of Illinois at Chicago, and the Illinois Poison Center in Chicago. These physicians reported a case involving serious complications from the use of baking soda given to a young infant to prevent colic.
They pointed out that the practice of using baking soda for this purpose is not uncommon as a home remedy. The case they presented involved an 11-day-old infant given a mixture of two scoops of baking soda mixed in water and baby formula. The child developed severe alkalosis with a pH of 7.95. Cerebral edema and seizures also were reported as part of the clinical picture.
Luckily, the child recovered and was discharged from the hospital in apparent good health. This case is an important one, and should be studied by emergency physicians because the use of baking soda to treat colic is frequently seen in many inner city communities.
Methanol Ingestions
Drs. Sawyer, Thole, LoVecchio and Beuhler from the Good Samaritan Regional Poison Center in Phoenix, AZ, reported on the disturbing practice by some young people who use commercial carburetor cleaning agents as inhalants.
These investigators performed a retrospective review of their poison center data over a four-year period. They identified 33 cases of the abuse of methanol-containing carburetor cleaner that had been reported to their center during the study.
They eliminated 12 cases because they included the use of co-ingestants. Of the remaining cases, nearly a third had acidosis, and three patients required administration of either ethanol or fomipozole to treat methanol toxicity.
The mean methanol level reported in the study was 28mg/dl. While most cases of methanol toxicity involved those who drink methanol-containing windshield washer fluid, this series should alert emergency physicians that there are other ways to become intoxicated with the substance.
Aspirin Overdose
Another abstract with information of special import to emergency practitioners was presented by Drs. Rivera, Kleinschmidt, Velez, and Shepherd from the North Texas Poison Center in Dallas. These investigators reported a case of delayed salicylate toxicity following a single overdose of aspirin. The case involved what is reported to be a single dose of aspirin where the initial levels were nearly undetectable, and the patient was without symptoms for a prolonged period (in this case, 35 hours) before symptoms developed.
The patient apparently ingested 120 aspirin tablets and several ciprofloxacin tablets two hours prior to arrival in the emergency department. Initial vital signs were essentially normal, and her first salicylate level was reported to be just 1 mg/dl. Repeat levels were obtained at about eight-hour intervals, and these levels never rose above 18 mg/dl.
At 35 hours post-ingestion, her salicylate level was reported to be 46 mg/dl. The patient was successfully treated using activated charcoal and sodium bicarbonate. She did not require hemodialysis.
This case reminds physicians that the absorption of salicylate may be delayed for prolonged periods, and that the history of ingestion may need to guide the period of observation and multiple repeat salicylate levels. As the authors of this work point out, the cause for the delay in salicylate elevations may be pyloric outlet spasm induced by salicylate, by the formation of a salicylate bezoar, or both.
Ibuprofen Overdose
Drs. Wiger and Gummin from the Medical College of Wisconsin and the Children's Hospital of Wisconsin Poison Center in Milwaukee presented the case of a 17-year-old with acidosis and coma related to an ibuprofen overdose. They noted that it is unusual for ibuprofen to be associated with the development of altered mental status. As this case demonstrates, however, very large ingestions of ibuprofen may be associated with development of altered mental status.
In this case, the patient had ingested somewhere in the range of 14g ibuprofen, and presented to the emergency department with a Glasgow comas score of 6. Initial lab values demonstrated a serious metabolic acidosis with a serum pH of 7.19 and an anion gap of 31.
After intensive supportive care and administration of sodium bicarbonate, the patient recovered and was discharged. This case should be kept in mind by all emergency physicians because while most cases of ibuprofen overdose do not cause serious harm, the possibility for severe consequences certainly does exist.
Intradigital Epinephrine Injections
Finally, Drs. Von Derau and Martin from the Seattle Washington Poison Center addressed the not uncommon problem of how to care for patients who may have sustained accidental intradigital epinephrine injections. These investigators pointed out that the usual teaching involves aggressive use of phentolamine and/or vasodilators to treat digital injections with epinephrine.
They reviewed 44 cases of unintentional intradigital epinephrine injections that had been managed by their poison center during a 40-month period. They concluded that most patients who suffer accidental digital injection of epinephrine can be successfully treated with supportive care as opposed to aggressive care using pharmacological agents such as phentolamine. They are quick to point out that a good prospective study needs to be performed to best define those patients who should receive more aggressive therapy as opposed to supportive care.
As I've mentioned in past columns, this annual meeting of medical toxicologists is consistently outstanding. While some may think the meeting holds interest only for those who practice toxicology, nothing could be farther from the truth. In reality, emergency physicians and others would be well served to put the annual meeting of the North American Congress of Clinical Toxicology on their CME agenda. Information about next year's meeting, Sept. 4-9 in Chicago, is available at the American Academy of Clinical Toxicology's web site (www.clintox.org). This meeting will celebrate the 50th anniversary of the first established poison control center in the country, founded in Chicago in 1953. I encourage all emergency physicians to consider attending.
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© 2002 Lippincott Williams & Wilkins, Inc.